Preventive Agents/Products
Board Review DH227
Concorde Career College
Lisa Mayo, RDH, BSDH
Fluoride
• Fluoride in average topical treatment
– 45mg for NaF
– 61.5mg for APF
• Toxic Dose
– Induce emesis
– F ion can bind to a liquid of MILK or LIME JUICE
– Call 911
• Safe Dose
– Adult: 1.25-2.5G
– Child: 0.5G
• Lethal Dose F
– 32-64mg of PURE fluoride per Kg body weight
– Adult: 5-10G
– Child: 0.5-1.0G
Fluoride: Toxicity
• Symptoms being within 30min – 24hrs
• GI: hydrochloric acid acts on F ion to form
hydrofluoric acid – irritates stomach lining
– Nausea, vomit, diarrhea, abdominal pain, increase
salivation, thirst
• Systemic Involvement
– Symptoms of hypocalcemia
– Hyper-reflexia, convulsions, parasthesia
– Cardiac failure, resp. paralysis
• Treatment
– Induce vomiting (emesis)
– Administer F-binding agents
Fluoride: Toxicity
• Skeletal fluorosis
– Results after long-term use of water with 1025ppm for industrial exposure
• Dental fluorosis
– When excess F is in drinking water during the
years of tooth development
– Birth til 12-16yrs or when crowns of permanent
3rd molars are completed
Amt F Ingested
Emergency Tx
≤5mg/kg
1. Admin fluoride-binding agent
≥5mg/kg
1. Induce vomiting (emesis)
2. Admin fluoride-binding agent
3. Seek medical tx
≥15mg/kg
1. Seek medical tx
2. Induce vomiting
3. Cardiac monitoring
Question
What is the first measure that should be taken
when a child ingests a toxic amount of topical
fluoride?
a.
b.
c.
d.
Drink milk
Induce vomiting
Seek medical attention
Administer fluoride-binding agent
Answer
What is the first measure that should be taken
when a child ingests a toxic amount of topical
fluoride?
a.
b.
c.
d.
Drink milk
Induce vomiting
Seek medical attention
Administer fluoride-binding agent
Question
How long can acute fluoride toxicity last?
a.
b.
c.
d.
1 hour
10 hours
10 minutes
Up to 24 hours
Answer
How long can acute fluoride toxicity last?
a.
b.
c.
d.
1 hour
10 hours
10 minutes
Up to 24 hours
Question
What is the safely tolerated dose of topical
fluoride?
a.
b.
c.
d.
>5mg/kg
>15mg/kg
¼ the certainly lethal dose
The amount of drug likely to cause death if not
intercepted by antidotal therapy
Answer
What is the safely tolerated dose of topical
fluoride?
a.
b.
c.
d.
>5mg/kg
>15mg/kg
¼ the certainly lethal dose
The amount of drug likely to cause death if not
intercepted by antidotal therapy
Fluoride Absorption In Body
• Begins in stomach as hydrogen fluoride
– Rate depends on solubility of F compound &
gastric activity
– ↓ when taken with milk/food
– Most absorbed in 60min
• Whatever not absorbed by stomach – small
intestine
– Plasma in blood carries it through body
– Max blood levels reached in 30min after intake
Fluoride Distribution In Body
• Strong affinity for calcified tissues – 99% located
in mineralized tissues
• Highest concentration in surfaces closest to the
source supplying F: Highest level is on the tooth
surface
• Stored in crystal lattice of teeth and bones
• Amount stored varies w/ intake amt, exposure
time, age/stage of development
• Exposed dentin F concentrations < enamel
Fluoride Excretion In Body
• Kidneys by urine
• Small amts in sweat and feces
• Limited transfer via breast milk
Fluoride Deposition In Body
• Pre-Eruptive Stage
– Deposited during formation of enamel starting at DEJ
– Incorporated in crystals during mineralization
– New crystals = fluoroapatite = less soluble then hydroxyapatite
– Results = shallower grooves, less fissures
• Post-Eruptive Stage
– F benefits from topical application only
– Uptake most rapid on enamel surface during 1st 2yrs after eruption
– Topical = fluorhydroxyapatite (Free F ion moves into crystal & forms)
– Mature enamel reacts with fluoride to primarily form CaF
– Demin: CaF dissolves 1st, then hydroxyapatite, then
fluorhydroxyapatite
Fluoride: Role in Caries Process
• Reacts with hydroxyapatite to form FLUORAPATITE
• Interferes with bacterial metabolism
– High concentrations: bactericidal
– Low concentrations: bacteriostatic
– Has substantivity: ability to be bound to pellicle and tooth
surface and be released over a period of time with
retention of potency
• Aids in accelerated maturation
– At time of tooth eruption, enamel not fully calcified and
undergoes post-eruptive period during which enamel
calcification continues
– F will be rapidly absorbed into the enamel
Fluoride Therapy
• Methods
– Systemic: water, supplements, food
– Topical: toothpaste, rinse, in-office
• Systemic
– Most F absorbed by stomach and intestines and
stored in the bone as fluoroapatite
– Most efficient from 6mo-14yrs
– Excreted by kidneys
Fluoride Therapy
• Systemic
– Fluoridation: adjustment of F ion content of
domestic water supply to the optimum physiologic
concentration that will provide max. protection
against caries and enhance appearance of the
teeth with min. possibility of producing
objectionable enamel fluorosis
– 1965: 1st communities fluoridated
– Avg cost: $0.13 - $5.48 per person/year
– Most cost effective way to bring F to a community
Fluoride Therapy
Community Fluoridation
– Levels range 0.7-1.2ppm mg/L
– Warmer climate = lower
– Colder climate = higher
– EPA monitors
– Compounds used:
1. Sodium fluoride
2. Sodium silicofluoride
3. Hydrofluosilic acid
NBQ
To deliver water to a community through water
fluoridation. If a person lives in a colder climate,
what ppm fluoride would be expeted?
a.
b.
c.
d.
0.7ppm
0.9ppm
1.2ppm
1.4ppm
NBQ
To deliver water to a community through water
fluoridation. If a person lives in a colder climate,
what ppm fluoride would be expeted?
a.
b.
c.
d.
0.7ppm
0.9ppm
1.2ppm
1.4ppm
Fluoride Therapy
Community Fluoridation
– Most effective in reducing caries smooth surface
– Least effective in reducing caries pit and fissures
– Ant teeth have better protection then post
– Adv:
1.
2.
3.
4.
Decrease caries by 25% in post eruptive teeth
Cost effective
Safe
Benefits kids and adults
Fluoride Therapy
Community Fluoridation
– Disadv.
1. Have to drink community water
– Reasons why not universal
1. Controversial effects of systemic F
2. Public not informed of benefits of F
3. Powerful Lobbyist's
- Courts have upheld the legality of water
fluoridation
Fluoride Therapy
• Tooth colored restorations: NaF
• Topical
– APF: Acidulated Phosphate F
– NaF: Sodium F
– SnF: Stannous F
– MFP: monofluorophosphate
Fluoride Therapy: Topical
• Stannous F
–
–
–
–
Unpleasant taste, Unstable solution
Stains teeth in demin areas
Gingival sloughing
Discoloration restorations
• APF
– Not for tooth colored restorations: acid will etch glass
components - pits and roughens material
• Varnish
–
–
–
–
5% NaF (22,600ppm)
ADA recommended
Desen roots, Caries (14% more effective than other topicals)
Retained for 24-48HRS during which time F released for
reaction w/enamel
– 2 to 4 times per year
Fluoride Therapy
NaF
APF
SnF2
Concentration
2%
1.23%
8%
ppm F
9,050
12,300
19,360
Efficacy
29%
28%
32%
pH
9.2
3.0-3.5
2.1-2.3
Adverse Rxns
None
May etch rest
materials
Brown staining,
gingiva rxn
Application Freq
4x/yr ages 3,7,10,13 1-2x/yr
1-2x/yr
Fluoride Therapy: Topical
• Safety
– Under 6yrs – no rinses (swallow)
• Self-Applied F
– Tray, rinse, toothbrush
– Frequent, low concentrations F to promote remin.
– Bacteriostatic
At-Home Fluoride
•
•
•
•
Application: tray, rinse, toothbrush
Low concentration, frequent application
Promote remin (bacteriostatic effect)
Ex:
1. Rinse: 0.05% NaF, 225ppm
2. Dentifrice: 400-1500ppm
3. Gels: 0.4% Stannous (1,000ppm) pH2.8-5.0 or
1.1% NaF (5,000ppm)
Question
Which of the following topical fluoride delivery
systems is BEST for an individual with rampant
caries?
a.
b.
c.
d.
Tray
Rinse
Painting
Toothbrushing
Answer
Which of the following topical fluoride delivery
systems is BEST for an individual with rampant
caries?
a.
b.
c.
d.
Tray
Rinse
Painting
Toothbrushing
Question
Self-applied fluoride rinses are:
a.
b.
c.
d.
Rarely suggested for adults
Available by prescription only
Are effective in caries prevention and control
Too expensive to be considered cost-effective
Answer
Self-applied fluoride rinses are:
a.
b.
c.
d.
Rarely suggested for adults
Available by prescription only
Are effective in caries prevention and control
Too expensive to be considered cost-effective
Question
In what percentage is professional strength, inoffice sodium fluoride gel?
a.
b.
c.
d.
2%
5%
1.2%
1.23%
Answer
In what percentage is professional strength, inoffice sodium fluoride gel?
a.
b.
c.
d.
2%
5%
1.2%
1.23%
Dietary Fluoride Supplements
• Recommended for kids who live in areas with inadequate
water fluoridation
• NOT recommended for pregnant women
• Fluoride in foods: tea/fish contain large amounts
• Includes tablets, lozenges, drops, liquids, F-vitamin
preparations containing NaF (most common) or APF
• Tablets intended to be chewed, swished and swallowed
• Drops are used on infants
• Daily use better at caries reduction then systemic F
• Not recommended on infants who are breastfed (breast
milk contains 0.0004ppm)
• School-based F supplement programs yield 30%↓ caries
Question
What is the best method of fluoride application for
caries prevention?
Concentration
Frequency
a. Low
Low
b. Low
High
c. High
Low
d. High
High
Question
What is the best method of fluoride application for
caries prevention?
Concentration
Frequency
a. Low
Low
b. Low
High
c. High
Low
d. High
High
ADA Table
Age
Concentration of Fl
Ion in Drinking
Water
≤0.3ppm
0.3-0.6ppm
≥0.6ppm
Birth-6mo
None
None
None
6mo-3yrs
0.25mg/day
None
None
3-6yrs
0.5mg/day
0.25mg/day
None
6-16yrs
1.0mg/day
0.5mg/day
None
Board Question
What agency monitors the amount of fluoride in
community water supply?
a.
b.
c.
d.
Bureau of Land Management
Food and Drug Administration
Environmental Protection Agency
Occupational Health and Safety Administration
Board Question
What agency monitors the amount of fluoride in
community water supply?
a.
b.
c.
d.
Bureau of Land Management
Food and Drug Administration
Environmental Protection Agency
Occupational Health and Safety Administration
Board Question
All of the following are added to the water for
community water fluoridation, EXCEPT one.
a.
b.
c.
d.
Sodium fluoride
Sodium silicofluoride
Hydrofluorosilic acid
Acidulated phosphate fluoride
Board Question
• All of the following are added to the water for
community water fluoridation, EXCEPT one.
a.
b.
c.
d.
Sodium fluoride
Sodium silicofluoride
Hydrofluorosilic acid
Acidulated phosphate fluoride
Systemic Fluoride Pre-Eruptive
• Circulates in the bloodstream and is incorporated into the
enamel of developing teeth
• Rapidly absorbed in stomach and small intestine
• Effective for 6mo-14 years of age
• Amount not used is excreted through kidneys
• Once thought to be primary action, now understood to be a
minor effect compared with the post-eruptive action of
fluoride
• F incorporated into the mineralized tooth structure during
tooth development by the replacement of hydroxyapatite
w/fluorapatitie during enamel formation
Demineralization
• Dissolution of the Calcium and Phosphate ions
from the hydroxyapatite crystal of the tooth that
are lost into the plaque and saliva
• Occurs when pH drops below
– 4.5-5.5 enamel
– 6.0-7.0 cementum
• Prevention
1. Good plaque control
2. Fluoride uptake
3. Restricted sugar intake
Remineralization
• Calcium, phosphate, other ions in saliva and
plaque are re-deposited into previously
demin. areas
• When pH rises above “critical levels”
• Remin. areas tend to be stronger and more
acid resistant then original structure
– Fluoroapatite has been formed
• Requirements same as demin.
NBQ
Prevention and control of smooth surface dental
caries if MOST effectively managed by:
a.
b.
c.
d.
e.
Biannual dental hygiene recall visits
Early radiographic detection
Dental sealant application
Diet rich in fermentable carbohydrates
Fluoride therapy
NBQ
Prevention and control of smooth surface dental
caries if MOST effectively managed by:
a.
b.
c.
d.
e.
Biannual dental hygiene recall visits
Early radiographic detection
Dental sealant application
Diet rich in fermentable carbohydrates
Fluoride therapy
NBQ
Acidulated phosphate fluoride (APF)
a. Is an acidic preparation of stannous fluoride
b. Is difficult to use because of its instability in
solution
c. Should be applied every 6 months
d. Is not recommended for children
e. Is commonly recommended for OTC preparation
NBQ
Acidulated phosphate fluoride (APF)
a. Is an acidic preparation of stannous fluoride
b. Is difficult to use because of its instability in
solution
c. Should be applied every 6 months
d. Is not recommended for children
e. Is commonly recommended for OTC preparation
Chemotherapeutics
• Definition: Treatment of disease by means of chemical substances or
pharmaceutical agents
• Purposes
In-Office
1. Pretx rinse to reduce org.
2. Pretx rinse to reduce aerosol contamination
3. Facilitate impressions
4. Rinse and fresh breathe
5. Replace surface F removed during tx
6. F rinse as part of caries prevention pgrm
At Home
1. Vigorous rinsing to aid in oral cleansing
2. Saline rinse after nonsurgical perio therapy
3. Caries prevention
Chemotherapeutics
• Commercial Mouthrinses
1. Oxygenating Agents
Cleanse via effervescent action
Antimicrobial
Active ingredients: H2O2, Na perorbate, Urea peroxide
Concerns: black hairy tongue, sponginess of tissues,
hypersensitivity of exposed roots, demin.
tooth surface
2. Antimicrobial
To reduce oral microbial count
Inhibit bacterial activity
Active ingredients: Chlorahexidine, iodine, iodophores,
fluorides, phenol, essential oils, cetylpyridinum
chloride, sanguinarine
Chemotherapeutics: CHX
• Mechanism of Action
– Bactericidal: active against wide range Gram (+) & Gram (-)
– Alters cell wall so that lysis occurs – cell destroyed
– Substantivty: rapidly absorbed into teeth and pellicle and
is released slowly
• Clinical Uses
– Preprocedural rinse, decrease supragingivial bacteria,
inhibits gingivitis, short-term adjunct following SRP,
implants, suppresses S.mutans (may aid in prevention
caries)
• Side effects (next slide)
Chemotherapeutics
Side Effects
–
–
–
–
–
–
–
Temp loss of taste
Bitter taste
Burning sensation of mucosa
Dryness
Epithelia desquamation
Discoloration of teeth, tongue, restorations
Slight increase supragingival calculus formation
(related to dead bacteria that remin. as a result of
bactericidal action)
Antimicrobials
• Tobacco User
– Advise to use non-alcohol
– Alcohol + tobacco = synergistic effect, increase risk of cancer
• Cancer Pt
– Rinse baking soda/saline followed by H2O/CHX, avoid alcohol
mouthrinses
• Acute Perio Disease
– Warm water or weak saline solution, CHX
• Alcohol Condition
– Avoid alcohol rinses, if being treated with DISULFIRAM
can have medical emergency
Xylitol
• Used in food/snack items as a noncariogenic
sweetener
• Evidence of anticariogenic and cariostatic properties
• Control dental caries in people with moderate to
high risk for caries
• Reduced S.mutans
• Makes plaque biofilm less adhesive
• Allows enamel surface to remin.
Novamin
• Ca and Phosphate ions in ACP will seek out
areas of demin and enhance enamel remin.,
occlude dentinal tubules, increase F uptake,
prevent caries progression
• High risk caries groups should use
• People w/ sensitivity should use
• Should be used in combo with F
• Toothpaste, polish paste, sealant
Recaldent / Casein Phosphopeptides
• Enhance the effects of F & provides a
supersaturated environment of Ca and P for
remin.
• Not a F substitute
• High caries risk, sensitivity issues
• Caries prevention
• Gum, pastes, professional application
Oral Irrigation
• Effective method of delivery for
Chemotherapeutic agents
• Disrupts loosely adherent microbial colonization
• Point tip perpendicular to long
axis of tooth
BOARDS: GOOD FOR GINGIVITIS REDUCTION
Oral Irrigator Indications
• Delivery of liquid antimicrobial agent
• Presence of gingival inflammation and
bleeding
• Disruption of loosely adherent plaque
• Ortho
• Least effective method of removing plaque
when compared to other oral physiotherapy
aids
NBQ
What is the purpose of an oral irrigator?
a. To remove subgingival plaque that is adherent to
the tooth
b. To remove supragingival plaque that is adherent
to the tooth
c. To disrupt loosely adherent plaque in the sulcus
d. To disrupt tightly adherent plaque in the sulcus
NBQ
What is the purpose of an oral irrigator?
a. To remove subgingival plaque that is adherent to
the tooth
b. To remove supragingival plaque that is adherent
to the tooth
c. To disrupt loosely adherent plaque in the sulcus
d. To disrupt tightly adherent plaque in the sulcus
Supplemental Aids
•
•
•
•
•
•
•
•
•
•
•
Disclosing agents
Floss and tape
Floss threader
Tufted floss, yarn, gauze: embrasures, pontics, ortho, implants
End Tuft
Interproximal: embrasures, pontics, FPD, ortho, perio splints,
proximal cavities, class V furcation’s, delivering chemotherapeutics
Wooden/plastic/triangular wedges/sticks: embrasures
Toothpicks, perio aid, rubber tip: embrasures, concavities,
furcation's, ortho, apply chemotherapeutics, biofilm removal
at/below gum line
Tongue cleaners
Power brush
Oral Irrigation
Denture/Partial Care
1. Rinse under water
2. Brush: water, soap, non-abrasives (toothpaste, paste,
powders)
3. Immersion: solvent, detergent, prevent drying them out,
use mouthrinse for pleasant taste, daily
Alkaline Hypochlorite: bleach, loosen debris and stains,
dissolve plaque matrix
Alkaline Peroxide: loosen debris, stains, not for heavy stains
Dilute Aids: dissolve inorganic components of deposits
Enzymes: break down plaque PRO
Disinfectants: NaCl - antimicrobial agent, not use metal
dentures, good stain remover, soak 10-15min
4. Mechanical cleanser: ultrasonic, magnetic, sonic
Denture/Partial Oral Lesions
• Reactive / Traumatic
– Acute or chronic
– Ulcers, focal hyperkeratosis, denture-induced fibrous
hyperplasia, redness
• Infectious Lesions
– Denture stomatitis, angular cheilitis, candidiasis/thrush
• Mixed Reactive
– Etiology: Trauma and infection
– Root caries, papillary hyperplasia
Denture/Partial Oral Lesions
• Systemic-Disease Related
– Paget’s Disease: rapid resorption and deposition of bone,
enlarged jaw bones, fuzzy-looking on radiographs, etiology
unknown
– Acromegaly: overproduction growth hormone, enlarged
mandible, lips, tongue, hands, feet
– Oral Cancer
– Pernicious Anemia: vitamin deficiency (iron)
Power Toothbrush Indications
• People with manual dexterity problems
• Caregivers providing oral care
• Implants
Interdental Brushes Indications
•
•
•
•
•
Open embrasure spaces
Diastema’s
Implants – only if plastic wire
Mild arthritis
Accessible Class III or IV furcation areas
Tufted Brushes Indications
• Rotated teeth
• Hard to access third molars
• Accessible Class III or IV furcations
Toothpick Indications
•
•
•
•
Accessible furcation areas
Shallow pockets
Normal sulcus depths
Patient who already uses toothpicks
Floss Threader Indications
• Fixed bridges
• Ortho
• Use in conjunction w/dental floss
Floss Holder Indications
• People who are physically / dexterity
challenged to use dental floss with fingers
• Those with large hands
• Gag reflex
Tufted Floss Indications
• Bridges
• Ortho
• Does not need floss (bridge) threader
Dental Floss
• Indicated for use proximal surfaces
• Aids in min interprox decay
• Should start flossing child’s teeth when
proximal surfaces contact each other
NBQ
Powered toothbrushes may be:
a. Indicated for individuals who are physically or
mentally challenged
b. Effective tools for subgingivial plaque control in
pocket depths up to 4mm
c. More traumatic to gingiva and cementum that
manual toothbrushes
d. Contraindicated for individuals with mitral valve
prolapse
e. More difficult to use and require increased
instructions time
NBQ
Powered toothbrushes may be:
a. Indicated for individuals who are physically or
mentally challenged
b. Effective tools for subgingivial plaque control in
pocket depths up to 4mm
c. More traumatic to gingiva and cementum that
manual toothbrushes
d. Contraindicated for individuals with mitral valve
prolapse
e. More difficult to use and require increased
instructions time
NBQ
Which of the following home care
armamentariums is the LEAST effective plaque
control tool for a client with dental implants and
a fixed prosthesis?
a.
b.
c.
d.
e.
Tapered end tuft toothbrush
Soft bristled, multi-tufted nylon toothbrush
Rubber tip stimulator
Mild abrasive, ADA approved toothbrush
Unwaxed dental floss
NBQ
Which of the following home care
armamentariums is the LEAST effective plaque
control tool for a client with dental implants and
a fixed prosthesis?
a.
b.
c.
d.
e.
Tapered end tuft toothbrush
Soft bristled, multi-tufted nylon toothbrush
Rubber tip stimulator
Mild abrasive, ADA approved toothbrush
Unwaxed dental floss
NBQ
Interdental cleaning devises
a. Conform to the anatomy of the proximal tooth
surface
b. May result in the loss of interdental papillae
c. Are selective on the architecture and position of
the gingiva
d. Compare favorably with toothbrushing for
interdental bacterial plaque removal
e. Require excellent manual dexterity to manipulate
NBQ
Interdental cleaning devises
a. Conform to the anatomy of the proximal tooth
surface
b. May result in the loss of interdental papillae
c. Are selective on the architecture and position of
the gingiva
d. Compare favorably with toothbrushing for
interdental bacterial plaque removal
e. Require excellent manual dexterity to manipulate
Oral Deposits
• Acquired Pellicle
– Amorphous, acellular, unstructured
– Reforms w/in min. after removal
– Composed of salivary glycoPRO
• Materia Alba
– Loosely adherent mass of bact and cellular debris
– Unstructured
– Resembles cottage cheese in appearance
– Forms over plaque in neglected mouths
– Can be removed by oral irrigation or water spray
Oral Deposits
• Food Debris
– Unstructured, loosely attached
– Collects at cervical 1/3 and interprox
– Can be removed by oral irrigation/water spray
• Plaque (Biofilm)
– Dense, nonmineralized mass of bacteria
– Organized and closely adherent
– Caries and perio d. are infectious d. caused by biofilm
– Not caused by single microorganism
– Pellicle – Biofilm - Calculus
Biofilm
Formation Stages
1. Pellicle formation
•
Absorption of glycoPRO from saliva
2. Bacterial colonization
•
Colonies form and coalesce
3. Maturation
•
Bact multiply and may increase thickness
4. Matrix formation
•
•
•
Supragingival biofilm: saliva
Subgingival biofilm: sulcular fluid
Both contain polysaccharied (adherence properly)
Biofilm Composition
Days
Biofilm Composition
1-2
Cocci, aerobic, gram (+)
S.mutans, S.sanguis, Actinomyces
2-4
Cocci, may see filaments and rods
Colonization occurs in stratified layers against the tooth surface,
matrix
4-7
Filamentous forms ↑, fusobacteria appear
Biofilm thicken at margin
7-14
Vibrios and spirochetes appear, gram (-), aerobic, ↑WBC
Sign of inflammation begin
14-21
Densely packed vibrios, spirochetes, filamentous bact.
Biofilm blooms into mushroom shape attached by a narrow base
that incorporates channel to capitalize on fluid movement
Gingivitis
Biofilm
• 80% water
• 20% inorganic/organic elements
– 70-80% microbes
– Inorganic: Ca, phosphorous, fluoride
– Organic: CHO, PRO, Lipids
Calculus
• Mineralized plaque
• Formation
 24-48 hours
 Centers grow and coalesce
 Ave time for detectable calculus = 12 days
• Pellicle – Plaque biofilm – Mineralization
• Sub-g vs Supra: sub harder and darker in color
(pigments from blood breakdown)
– Attach supra via acquired pellicle
– Attach sub directly to cementum
• Significance
 Allows for bact attachment
 DOES NOT cause pocket formation!!!
Calculus Composition
• 10-30% water and organic elements
Microbes
Cells
• 70-90% inorganic
Ca, phosphorous, carbonate, sodium, magnesium,
potassium, trace elements, fluoride
• Rapid formers: greater Ca-phosphate
• Slow formers: greater pyrophosphate
• Supra
Calculus
– Nutrient is saliva
– Color often white, yellow, gray
– Most commonly found near opening of salivary
gland ducts
• Sub-g
– Nutrient source crevicular fluid & inflammatory
exudate
– Color dark brown, dark green, black
Calculus Detection
• Explorers
– 11/12 and pigtail for posteriors
– Orban-type for ant and cervical 1/3 of post
• Dry teeth w/ compressed air
• Radiographs (not always show calculus)
Question
From which of the following is calculus most
easily removed?
a.
b.
c.
d.
Pellicle
Enamel
Cementum
Restorative material
Answer
From which of the following is calculus most
easily removed?
a.
b.
c.
d.
Pellicle
Enamel
Cementum
Restorative material
Stain Color
Cause
Extrinsic
Intrinsic
Yellow/Brow
n
Biofilm, food pigments, CHX, SnF
x
Orange, Red
Chromogenic bact in plaque
Poor OH, ant teeth
x
Green
Chromogenic bact, poor OH
Fungi, Decomposed hemoglobin
x
Black Line
Bact (gram +), iron
1/3 of F/L
x
Brown
Tobacco, SnF, CHX, Cetylpyridinium,
Food Source, Betel Nut
x
Blue-Green
Mercury, Lead Dust (occupational
exposure), poro OH, dark beverages
x
Gray, Black
Metallic Ions from amalgam
x
Gray, Brown
Caries
x
x
Question
What kind of stain does stannous fluoride
cause?
a.
b.
c.
d.
Brown
Green
Black
Orange
Answer
What kind of stain does stannous fluoride
cause?
a.
b.
c.
d.
Brown
Green
Black
Orange
Stain
Intrinsic (endogeneous)
– Not removable
– Possible causes
1.
2.
3.
4.
Pulpal necrosis
Internal resorption
Excessive systemic fluoride
Tetracycline
Question
Which of the following stains is not caused by
poor oral hygiene or smoking?
a.
b.
c.
d.
Brown
Orange
Bluish-green
Yellow-brown
Answer
Which of the following stains is not caused by
poor oral hygiene or smoking?
a.
b.
c.
d.
Brown
Orange
Bluish-green
Yellow-brown
Question
An industrial worker presented to the dental
office with a bluish-green stain on his teeth. The
inhalation of which type of metallic dust from
occupational exposure caused this stain?
SELECT ALL THAT APPLY.
a.
b.
c.
d.
Gold
Coal
Nickel
Copper
Answer
An industrial worker presented to the dental
office with a bluish-green stain on his teeth. The
inhalation of which type of metallic dust from
occupational exposure caused this stain? SELECT
ALL THAT APPLY
a.
b.
c.
d.
Gold
Coal
Nickel
Copper
Toothbrushing
Review Methods Handout
Roll
Bass Sulcular
Modified Bass
Stillman
Modified Stillman
Fones(circular)
Horizontal (scrub)
Leonard (Vertical)
Occlusal
Question
• If your patient was a child with limited
dexterity what method of brushing would you
recommend?
Answer
• Roll or Fones
– Fones 1st technique for kids prior to dexterity
development
– Roll: good as a technique prior to being able to
use sulcular
Question
• What method of brushing is recommended for
a 12 year old patient in full orthodontics?
Answer
• Charters
– Filaments 45 degree angle toward occlusal
– Enough pressure to force filaments between teeth
– Vibrate back and for 10sec 2-3x/teeth
– Heel/toe for anterior lingual’s
Question
A 14-yr old girl presents to the office with
swollen, bleeding gingiva. Which of the
following would you recommend?
a.
b.
c.
d.
Oral irrigator
End-tuft toothbrush
Soft toothbrush
Disclosing solution
Answer
A 14-yr old girl presents to the office with
swollen, bleeding gingiva. Which of the
following would you recommend?
a.
b.
c.
d.
Oral irrigator
End-tuft toothbrush
Soft toothbrush
Disclosing solution
Question
A patient presents with misaligned mandibular
anterior teeth. Which of the following oral
physiotherapy aids would be BEST to
recommend to clean these teeth at home?
a.
b.
c.
d.
Dental tape
End-tuft toothbrush
Interdental brush
Toothpick holder
Answer
A patient presents with misaligned mandibular
anterior teeth. Which of the following oral
physiotherapy aids would be BEST to
recommend to clean these teeth at home?
a.
b.
c.
d.
Dental tape
End-tuft toothbrush
Interdental brush
Toothpick holder
Dentifrices
•
•
•
•
•
•
•
↓ Caries
↓ Biofilm formation
↓gingivitis
↓ Supragingivial calculus
↓ tooth sensitivity
Remove stains
Whitening
Dentifrices
• Abrasives (20-40%)
– Clean and polish
– Physically remove biofilm and stain
– Smooth teeth: resists bact. accumulation & stains
– Factors that affect: particle hardness, size, shape, toothpaste pH,
water and glycerin content, salivary characteristics
• Humectants (20-40%)
– Retain moisture
– Prevent hardening when exposed to air
– Stabilize preparation
• Detergents (1-2%)
– Loosen debris
– Surfactant (↓ surface tension)
– Foaming and emulsify debris
• Binders (1-2%)
Dentifrices
– Thickener
– Prevent separation of solid and liquid ingredients
• Sweeteners (1-2%)
– Create a favorable taste
– Xylitol, glycerine, manitol, sorbitol, saccharine
• Coloring agents
– Attractiveness but may cause mucosal rxns
– Vegetable dyes, tartrazine
Dentifrices
• Flavoring agents
– Mask other ingredients and present a pleasant
taste and after-taste
– Essential oils, peppermint, cinnamon, spearmint,
clove, wintergreen, menthol
• Preservatives (2-3)
– Prevent bact growths, formaldehyde,
dichlorinated phenols
– Prolong shelf life
– Alcohols, benzoate
Specialty Dentifrices
• Whitening: some use hydrogen peroxide and others use carbamide
peroxide
• Tooth sensitivity: occlude dentinal tubules
– Potassium nitrate/citrate/chloride; strontium chloride, sodium
citrate, SnF
• Gingivitis reduction
– SnF, triclosan, zinc citrate + NaMFP
• Calculus reduction
– Tetrapotassium pyrophosphate
– Tetrasodium hexametaphosphate
– Zinc chloride, zinc citrate, triclosan/copolymer
Specialty Dentifrices
• Caries Prevention
– NaF, Na-monofluorophosphate, stannous, xylitol
• Halitosis
– Essential oils, chlorine dioxide,
triclosan/copolymer, stannous fluoride, sodium
hexametaphosphate
Mouthrinses
• Cosmetic/Breath-Freshner or Therapeutic
– ↓ biofilm, bact, inflammation
• General Functions
– Oxygenation, astringent, buffering, deodorizer, anodyne(pain
relief), bacterio-static/cidal
• Ingredients
1.
2.
3.
4.
5.
6.
7.
Water: largest amt of volume
Alcohol: ↑ stability essential oils, ↓ surface tension, 15-30%
Flavoring agents: essential oils, eucalyptus oil, oil of
wintergreen
Aromatic waters: peppermint, spearmint, wintergreen
Coloring: must not discolor tissues
Sweetening agents
Astringents: zinc chloride, zinc acetate, alum tannic, acetic
acids, citric acids
CHX
• RX
• Most effective ant-plaque/gingivitis
chemotherapeutic agent
• Broad specturm bacterio-static/cidal
• Kills gram (+)(-) microbes
• US only 0.12%
• Mode of action: binds to hydroxyapatite and glycoPRO thus
↓ pellicle formation
• Absorbs into bacterial cell surface & interferes with
cell attachment
• Prevents bact accumulation
• Inactivated by SLS detergents
• 8-12 active hours
Question
Which of the following is the cause of dentinal
hypersensitivity?
a.
b.
c.
d.
Irritation to the pulp
Aggressive toothbrushing
Use of abrasive toothpaste
Movement of fluid within the dentinal tubule
Answer
Which of the following is the cause of dentinal
hypersensitivity?
a.
b.
c.
d.
Irritation to the pulp
Aggressive toothbrushing
Use of abrasive toothpaste
Movement of fluid within the dentinal tubule
Which of the following is a TRUE statements regarding
fluoride? (there is more then one right answer)
a.
b.
c.
d.
e.
f.
g.
Fluorine, the precursor to fluoride, is a naturally occurring element in air &
water
Fluoride is the end result of sodium bicarbonate mixing underground with
clean well water
The practice of civilized water fluoridation in populated areas is supported by
scientific research to help prevent widespread tooth decay in children
and adults.
Persons who are at risk for developing early gum disease in their teens are
recommended to buy meat and dairy with products injected with antibiotics to
support their immune system.
The level of fluoride recommended in drinking water for optimal dental health is
10.0ppm
Fluoridation of city water systems has been common practice in the US since WWI
Young children who ingest too much fluoride early in life develop teeth with short
roots.
Correct Answers: A, C, F
• B = derived from hydrofluoric acid
• D= person at risk for tooth decay are to brush
2x/day with fluoride toothpaste
• E= Should be 1.0ppm
• G= would develop white spots on enamel
Order the following 1-4 to show the most
reasonable steps in conducting a periodontal exam:
Collect samples from the pockets to conduct a bacterial
evaluation by microscope
Do a visual inspections of the gums, connective tissues,
lips, tongue
Measure the distance ranging between 1-12mm of the
gum tissue from the tooth
Grow a culture of the bacteria collected to exactly
identify strain and variety.
Answer
2, 3, 1, 4
For each symptoms, match correct
disorder
Symptom
Disorder
1. Migraine Headache
a. Oral Cancer
2. Canker sore, aphthous ulcer
b. Lichen Planus
3. Bright red, smooth area
c. Sutton’s Disease
4. Lines of lesions that form laceylooking patterns
d. TMD
5. Black tongue
e. Sjogren’s Syndrome
Answer
Symptom
Disorder
1. Migraine Headache
a. Oral Cancer
2. Canker sore, aphthous ulcer
b. Lichen Planus
3. Bright red, smooth area
c. Sutton’s Disease
4. Lines of lesions that form lacey-looking patterns
d. TMD
5. Black tongue
e. Sjogren’s Syndrome
1.
2.
3.
4.
5.
D
C
A
B
E